Schistosomiasis in Egypt

Schistosomiasis has a long history in Egypt, and the government has over sixty years of schistosomiasis control efforts. In 1922, the government of Egypt began a major control effort for schistosomiasis control, soon after the discovery that snails play an essential role in disease transmission-and the same year that Egypt received formal but limited independence from Britain. In the 1930s, the Ministry of Health created a department for endemic diseases, and in the 1940s the country passed a number of ordinances and decrees to control snails and to require examinations for at-risk populations. In 1955, the government recognized schistosomiasis as the largest health problem in Egypt and initiated a comprehensive control programme.

In 1972, the Minister of Health, Dr Mahmoud Mahfouz, presented Egypt’s first official report on national health policy, which included an analysis of economic losses from schistosomiasis. The report drew attention to the need for a comprehensive control programme, not only from a health and social perspective but also for purposes of economic development. Since 1969, the government of Egypt has expanded its schistosomiasis control efforts to Upper and Middle Egypt and the Suez Canal area, relying heavily on foreign assistance. In 1984, the government spent just over 8% of the per capita public health expenditure on schistosomiasis control; in 1988, expenditure was cut to 5.2% (Cochrane and Liese, 1992).

The many years of efforts in Egypt have had an impact on schistosomiasis prevalence. According to a World Bank report, prevalence of schistosomiasis was reduced in Middle Egypt from about 30% in the late 1970s to about 10% in the late 1980s (Cochrane and Liese, 1992:37), based on a study in 1977 that found positive samples in 29.4% of 2.7 million persons examined, and a study in 1988 that reported positive samples in 8.6% of persons examined. In Upper Egypt, the figures dropped from 21.7% positive samples in 1980 (in 775,000 persons examined) to 14.4% positive samples in 1988 (in over 3 million persons examined). The Ministry of Health reported that from 1982 to 1992 the prevalence of S. haematobium declined from about 15% to 1% in the Nile Delta and from 13% to 3% in Upper Egypt, and the prevalence of S. mansoni declined from about 40% to 20% in the Nile Delta (El Khoby, Galal, and Fenwick, 1993:2). Table 4.7 shows a collection of studies on declining prevalence of S.haematobium in three districts in Middle and Upper Egypt.

Table 4.7: Prevalence of S. Haematobium in three districts in Middle and Upper Egypt

1 “Report of an Independent Evaluation Mission on the National Bilharzia Control Programme in Egypt,” Transactions of the Royal Society of Tropical Medicine and Hygiene 81(supplement):1-57, 1985.

2 G. Webbe and S. El-Hak, “Progress in the Control of Schistosomiasis in Egypt (1985-1988),” Transactions of the Royal Society of Tropical Medicine and Hygiene 84(3):394-399, 1990.

3 Ministry of Health, unpublished data.

4 Adapted from Ministry of Health data, cited in EIPICO, 1995.

Studies in Egypt have demonstrated the effectiveness of praziquantel. Starting in 1983, selective population chemotherapy, using a single dose of praziquantel, was carried out in two highly endemic districts (with an overall prevalence of 73.5%) in the Beheira governorate in the Nile Delta, with sponsorship from UNICEF, the government of Egypt, and WHO. The study assessed the prevalence of schistosomiasis among school children, and the impact of a single dose of praziquantel (40 mg per kg of body weight). The study found that prevalence among school children declined from 75.4% to 40.9% in one district and from 80.5% to 30.8% in the other (El Malatawy et al., 1992). The same study carried out community surveys, which showed peak prevalence for schistosomiasis in the 15-24 years old age group in one district, and in the 15-44 years old age group in the other district. The report concluded, “The results of this operational research augur well for the future of large-scale chemotherapy in the control of schistosomiasis” (El Malatawy et al., 1992:55).

A separate report on the same research project, however, reached a somewhat different conclusion. This report, issued from UNICEF, argued that chemotherapy alone is not effective in reducing prevalence, concluding, “Schools where the prevalence was not reduced due to single treatment [were] usually located in villages with poor sanitation, no water supply and have no active health education; therefore, we cannot depend on diagnosis and treatment without having snail control, water and sanitation and health education activities” (El Malatawy, 1989:16). This report showed data for the second survey in which 7 primary schools (out of a total of 194 schools) continued to have high prevalence rates of 70-99%. These results would suggest that an integrated control approach is necessary to reduce schistosomiasis prevalence rates in some areas and that praziquantel administration alone is not sufficient in some situations.

The Ministry of Health began providing praziquantel free of charge in its schistosomiasis control programme on a nationwide basis in 1988, using a strategy of population-based selective chemotherapy. With this strategy, the MOH provided praziquantel only to infected persons, based on the results of individual diagnosis, also provided for free. Before 1988, the MOH used praziquantel only in some governorates and for certain age groups. The MOH began using praziquantel in school children in Middle Egypt, Beni Suef, Minya, and Assiut, in the early 1980s; one year later, Suhag and Kena were added. At that time, the MOH used about 0.5 to 1 million tablets a year, purchased directly from Bayer, at about double the current price (perhaps about US$ 0.57 per tablet). In 1992, the World Bank provided a loan of US$ 26.84 million over a period of six years, mainly to extend the national schistosomiasis control programme to five governorates in the Eastern and Western regions of the Nile Delta, with approximately US$ 12.87 million for purchase of praziquantel.

According to MOH policy, treatment is provided only on proof positive of infection. Annual surveys are carried out by MOH rural health personnel. Some rural residents may buy praziquantel on the private market, if they do not want to provide stool or urine samples to MOH personnel or if they disbelieve the MOH exam. The MOH exams are generally considered fairly accurate, although they vary depending on the quality of the technician, and the intensity of the infection. To promote treatment with praziquantel, the MOH has advertised on television, provided free diagnosis and free drugs, and made a particular effort to diagnose the disease in children (1-2 times a year). In urban school children, the MOH School Health Department has been responsible for the exams; in rural school children, the MOH Primary Health Care Department has been responsible.

The population is reported to be satisfied with praziquantel as treatment, considering the drug to be safe, effective, and good quality. Praziquantel is considered to cure 70-80% of people infected with schistosomiasis. The MOH purchases its praziquantel through open tender, and is required by law to have at least three bids and to accept the lowest price. Funds for praziquantel procurement by the MOH are provided by the World Bank. And the MOH has purchased approximately 6 to 9 million tablets a year, making it probably the largest single buyer of praziquantel in the world (Table 4.8), until recent purchases by the government of China. In 1992, the MOH examined about 22 million people in outpatient clinics and schoolchildren surveys, and treated about 2.3 million people who were diagnosed positive with praziquantel. Egypt’s strategy of population-based selective chemotherapy significantly reduced the prevalence of schistosomiasis in several studies (Barakat et al., 1995; El Malatawy et al., 1992; Farag et al., 1993), suggesting that substantial reductions have also been achieved on a national level. In short, the drug is considered a major success.

Table 4.8: Procurement of praziquantel by Egypt’s MOH

Number of tablets

Estimated value in L.E.

Estimated value in US$

1992

6.8 million

L.E. 5,984,000

US$ 1,802,410

1993

3.3 million

L.E. 2,904,000

US$ 872,072

Estimated value is calculated based on a procurement price of one tablet at L.E. 0.88

Estimated value in US$ is calculated based on an exchange rate in 1992 of US$ 1 = L.E. 3.32, and in 1993 of L.E. 3.33